Ambulance crew’s main focus during stroke care is symptom recognition and rapid transport to specialist units to maximise access to and effectiveness of time-critical treatments. However, in England, ambulance on-scene times (OSTs) (from when the ambulance arrives at the patients’ location to when it leaves for the hospital) have increased in recent years1 and appear extended compared with international services.2 3 Increased OSTs contribute to deteriorating symptom onset to arrival at hospital times, which represents worse care for patients.4 In 2022, the Getting It Right First Time (GIRFT) stroke report5 recommended an OST of less than 30 min for English ambulance services. Data on OST with suspected stroke patients across a 12-month period were collected from all English ambulance services to compare against the GIRFT recommendation and to identify any overall trend in OST.

Using a freedom of information request, the mean OST per month for all suspected stroke patients was requested from all 10 regional ambulance services in England6 for the time period December 2021 to November 2022. Cases included in the data provided were defined locally by each individual service. Monthly data are presented for each service as well as combined monthly averages and 12-month averages by service. A generalised linear model was fitted to the mean OST for suspected stroke patients in England across the 12 months reported to determine trends.

All 10 (100%) regional ambulance services supplied OST data (displayed in figure 1 and online supplemental table 1).

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Figure 1

Monthly mean on-scene times with suspected stroke patients for English ambulance services.

The mean OST (minutes:seconds) across the whole dataset was 37:40 (SD 4:25), with individual service values ranging from 29:15 to 43:21 for the 12 months. The lowest monthly mean OST in any service was 27:15 (service F, May 22) and the highest was 44:20 (service D, December 21). Only 10/120 (8%) service months were below the 30 min GIRFT target. Fitting a linear model to the country-wide averages, we see a non-significant reduction in OST of 5 s per month (p=0.09, R²=0.26).

Ambulance OST for suspected stroke patients in England consistently exceeds national recommendations of <30 min5 and is longer than international comparators,2 3 despite ambulance crew stroke care being broadly similar. Ambulance OST may include time for ambulance clinicians to contact stroke specialists to discuss the patient and the appropriate destination or to pass a pre-alert, but the exact nature of these pathways varies between hospitals. Prehospital stroke care should reflect national clinical guidelines, and the variation within the data and the difference between the best and worst performing services require further examination. While the 10 services reported cover different geographies with some differences in populations, ambulance crew stroke care options are limited and stroke pathways are similar, so the difference between the best and the worst performing services is difficult to explain. While emergency recanalisation treatments for stroke are so closely linked to time, a difference of up to 14 min OST between services may be clinically important. Limitations to this data include potential differences in case ascertainment as we did not specify the definition of ‘suspected stroke cases’ but we assume this was interpreted as suspicion of stroke by the attending clinicians. The aggregate nature of the data and the inclusion of patients who received emergency and non-emergency responses and patients within and outside of recanalisation treatment windows are also limitations. Due to the time-critical nature of emergency stroke care, it remains a priority for ambulance services to reduce OST. Further work in this area could use ambulance data linked to the English National Stroke Audit to explore the impact of ambulance OST on patient care and outcomes. Individual trusts should explore ambulance crew behaviour and practice in their areas, such as McClelland et al,7 and share learning and any initiatives that effectively reduce time. Prior research7 has suggested that ambulance clinicians are completing tasks, such as IV cannulation and 12-lead ECGs, that are unlikely to affect the transport decision or patient destination but which do contribute to prolonged OST.